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THE GREAT EASTERN SHIPPING CO. LTD.

MUMBAI
INVESTMENT DECLARATION FORM FOR FY 2017-18

Name: Staff Code : PAN No. :


Address :

Particulars required for finalising income tax on salaries for the year ending 31/03/2018.

This form is to be returned along with Proof of Investment to Mr. Aloysius Dmello, Fleet Accounts
Dept. Ocean House, duly filled up latest by 15/02/2018.

Description Max Amt. Amount


( In Rs. ) ( In Rs. )

___________________________________________________________________________________

A. Ded. U/s 80D in respect of Medical Insurance Premia :-


(Annexure III & III(a) )
(1a) Premium paid for self, spouse & children. 25,000 *
(1b) Preventive health checkup for self ,spouse & children
(Maximum 5,000/- within overall limit of Rs 25,000)
(2a) Premium paid for parents 25,000 *
(2b) Preventive health checkup for parents
(Maximum 5,000/- within overall limit of Rs 25,000)
____________________________________________________________________________________
B. (a) Ded. U/s 80CCC towards contribution to certain Pension Funds
(b) Ded. U/s 80C towards the following :-
1) Payment towards Life Insurance Premia (Annexure IV)
2) Payment towards Life Insurance Premia through salary
3) Contribution to PPF Scheme, 1968
4) Contribution made to UTI -ULIP / LIC –Dhanaraksha
5) Subscription to notified Equity Linked Saving Schemes
6) Subscription to Deferred Annuity Plan of any insurer
7) Subscription to National Savings Certificate
8) Tuition Fees paid to any university, college, school or other
Educational institution situated within India. (Annexure V)
9) Subscription to eligible equity shares or debentures approved
by any public finance institution.
10) Others ( if any )

Maximum aggregate amount of investments eligible for


rebate u/s 80C and 80CCC ( i.e. point B ) is Rs. 150,000.
____________________________________________________________________________

Note : * Maximum Deduction u/s 80D is Rs 25,000/-.Where the person is a Senior Citizen i.e. 60 years & above, the
deduction allowable will be Rs. 30,000/- instead of Rs. 25,000/- .

I hereby declare that all the above investments / amounts are paid by me out of my income chargeable to
tax for the Financial Year 2017-18.
Signature : _______________
Date : __________________
Annexure:- III

THE GREAT EASTERN SHIPPING CO. LTD. MUMBAI.

FORM OF DECLARATION TO BE FILED BY A PERSON WHO IS CLAIMING RELIEF


U/S 8OD FOR DEDUCTION IN RESPECT OF HEALTH INSURANCE PREMIA

NAME OF EMPLOYEE :

STAFF CODE :

I HEREBY DECLARE THAT I HAVE PAID AN AMOUNT OF RS. ___________ AS PREMIUM TO


___________________________________________________________________________________VIDE
CHEQUE NO ___________ DATED____________ DRAWN ON ______ ____________________________BANK,
OUT OF MY INCOME CHARGEABLE TO TAX FOR THE FINANCIAL YEAR 2017-18, TO KEEP IN FORCE THE
INSURANCE POLICY ISSUED IN ACCORDANCE WITH THE SCHEME MADE IN THIS BEHALF BY THE GENERAL
INSURANCE CORPORATION OF INDIA AND APPROVED BY THE CENTRAL GOVERNMENT IN THIS BEHALF OR
ANY OTHER INSURER AND APPROVED BY THE INSURANCE REGULATORY & DEVELOPMENT AUTHORITY
ESTABLISHED UNDER SUB-SECTION (1) OF SECTION 3 OF THE INSURANCE REGULATORY & DEVELOPMENT
AUTHORITY ACT, 1999 (41 OF 1999) ON THE HEALTH OF SELF / SPOUSE / SELF & SPOUSE / DEPENDANT
CHILDREN ( STRIKE OUT WHAT IS NOT APPLICABLE) AS PER DETAILS MENTIONED BELOW .

Name of Person Relation with Receipt. No. Receipt. Dt. Amount of


employee Premium (Rs)

Total

I ALSO CERTIFY THAT THOUGH THE PREMIUM RECEIPT IS IN THE NAME OF MY SPOUSE
_________________________, THE PREMIUM FOR THE SAME HAS BEEN PAID BY ME FROM MY INCOME
CHARGEABLE TO TAX FOR THE FINANCIAL YEAR 2017-18. ( STRIKE OUT IF NOT APPLICABLE )

I FURTHER CERTIFY THAT NEITHER MY SPOUSE NOR ANY OTHER FAMILY MEMBER HAS CLAIMED
NOR WILL CLAIM ANY DEDUCTION ON THE AFORESAID PREMIUM PAID BY ME UNDER ANY OF THE
PROVISIONS OF THE INCOME TAX ACT, 1961 IN THE INCOME TAX RETURN OR FROM THEIR RESPECTIVE
EMPLOYERS.

_______________________
( Signature of the employee )

NAME OF THE EMPLOYEE :


SC NO :

DATE :

Enclosed:- Original Sec 80D premium paid certificate.


THE GREAT EASTERN SHIPPING CO. LTD. MUMBAI.
( TO BE FILLED BY SPOUSE OF EMPLOYEE)

NAME OF EMPLOYEE :

STAFF CODE :

I HEREBY DECLARE THAT THE PREMIUM AMOUNT OF RS. ___________ PAID TO


___________________________________________________________________________________VIDE
CHEQUE NO ___________ DATED____________ DRAWN ON ______ ____________________________BANK,
WAS PAID BY MY SPOUSE __________________________OUT OF HIS /HER INCOME CHARGEABLE TO TAX
FOR THE FINANCIAL YEAR 2017-18, TO KEEP IN FORCE THE INSURANCE POLICY ISSUED IN ACCORDANCE
WITH THE SCHEME MADE IN THIS BEHALF BY THE GENERAL INSURANCE CORPORATION OF INDIA AND
APPROVED BY THE CENTRAL GOVERNMENT IN THIS BEHALF OR ANY OTHER INSURER AND APPROVED BY
THE INSURANCE REGULATORY & DEVELOPMENT AUTHORITY ESTABLISHED UNDER SUB-SECTION (1) OF
SECTION 3 OF THE INSURANCE REGULATORY & DEVELOPMENT AUTHORITY ACT, 1999 (41 OF 1999) ON THE
HEALTH OF SELF / SPOUSE / SELF & SPOUSE / DEPENDANT CHILDREN ( STRIKE OUT WHAT IS NOT
APPLICABLE) AS PER DETAILS MENTIONED BELOW .

Name of Person Relation with Recpt. No. Recpt. Dt. Amount of


employee Premium (Rs)

Total

I ALSO CERTIFY THAT THOUGH THE PREMIUM RECEIPT IS IN MY NAME , THE PREMIUM FOR THE
SAME HAS BEEN PAID BY MY SPOUSE __________________________ FROM HIS /HER INCOME
CHARGEABLE TO TAX FOR THE FINANCIAL YEAR 2017-18.

I FURTHER CERTIFY THAT NEITHER ME NOR ANY OTHER FAMILY MEMBER OTHER THAN MY
SPOUSE HAS CLAIMED NOR WILL CLAIM ANY DEDUCTION ON THE AFORESAID PREMIUM PAID BY ME
UNDER ANY OF THE PROVISIONS OF THE INCOME TAX ACT, 1961 IN THE INCOME TAX RETURN OR FROM
THEIR RESPECTIVE EMPLOYERS.

I FURTHER RESOLVE NOT TO AVAIL ANY BENEFIT /DEDUCTIONS UNDER THE INCOME TAX
ACT OR ASK FOR REIMBURSEMENT FROM MY EMPLOYER ( IF ANY)

_______________________
( Signature of the person )

NAME :

DATE :
Annexure:- IV

THE GREAT EASTERN SHIPPING CO. LTD. MUMBAI.


( TO BE FILLED WHERE THE PREMIUM RECEIPT IS IN THE NAME OF SELF/ SPOUSE /CHILDREN & PREMIUM PAID BY EMPLOYEE)

FORM OF DECLARATION TO BE FILED BY A PERSON WHO IS CLAIMING RELIEF U/S 80C FOR DEDUCTION IN RESPECT OF LIFE
INSURANCE PREMIA PAID
STAFF CODE :

NAME OF EMPLOYEE :

I HEREBY DECLARE THAT I HAVE PAID AN AMOUNT OF RS. ___________ AS PREMIUM TO


____________________________________________________________________________________ VIDE
CHEQUE NO ___________ DATED____________ DRAWN ON ______ ____________________________BANK, OUT OF MY INCOME
CHARGEABLE TO TAX FOR THE FINANCIAL YEAR 2017-18, TO KEEP
IN FORCE THE INSURANCE POLICY ISSUED IN ACCORDANCE WITH THE SCHEME MADE IN THIS BEHALF BY THE GENERAL
INSURANCE CORPORATION OF INDIA AND APPROVED BY THE CENTRAL
GOVERNMENT IN THIS BEHALF OR ANY OTHER INSURER AND APPROVED BY THE INSURANCE REGULATORY & DEVELOPMENT
AUTHORITY ON THE LIFE OF SELF / SPOUSE / SELF & SPOUSE /
DEPENDANT CHILDREN ( STRIKE OUT WHAT IS NOT APPLICABLE) AS PER DETAILS MENTIONED BELOW .

Name of Person Relation with Policy Number Policy Start Receipt. No. Receipt. Date.
Insured employee Date

Total

I ALSO CERTIFY THAT THOUGH THE PREMIUM RECEIPT IS IN THE NAME OF MY SPOUSE /FATHER / CHILDREN____________
(TO ENTER NAME), THE PREMIUM FOR THE SAME HAS BEEN
PAID BY ME FROM MY INCOME CHARGEABLE TO TAX FOR THE FINANCIAL YEAR 2017-18. ( STRIKE OUT IF NOT APPLICABLE )

I FURTHER CERTIFY THAT NEITHER MY SPOUSE NOR ANY OTHER FAMILY MEMBER HAS CLAIMED NOR WILL CLAIM ANY
DEDUCTION ON THE AFORESAID PREMIUM PAID BY ME UNDER
ANY OF THE PROVISIONS OF THE INCOME TAX ACT, 1961 IN THE INCOME TAX RETURN OR FROM THEIR RESPECTIVE
EMPLOYERS.

_______________________
( Signature of the employee )

DATE :

* IN CASE PREMIUM PAID IS IN RESPECT OF SELF PLEASE STRIKE OUT LAST 2 PARAGRAPHS.
(Annexure V)

THE GREAT EASTERN SHIPPING CO. LTD. MUMBAI.

FORM OF DECLARATION TO BE FILED BY A PERSON WHO IS CLAIMING RELIEF


U/S 8OC FOR TUITION FEES PAID TO ANY UNIVERSITY, COLLEGE, SCHOOL OR
ANY OTHER EDUCATIONAL INSTITUTION.

NAME OF EMPLOYEE :

STAFF CODE :

I HEREBY DECLARE THAT I HAVE PAID AN AMOUNT OF RS. ___________ OUT OF MY INCOME
CHARGEABLE TO TAX FOR THE FINANCIAL YEAR 2017-18, AS TUTION FEES AS PER THE
DETAILS MENTIONED BELOW TO THE SCHOOL / UNIVERSITY / COLLEGE / EDUCATIONAL
INSTITUTE, SITUATED WITHIN INDIA FOR THE PURPOSE OF FULL TIME EDUCATION OF MY
CHILDREN.

Name of Child Name & Add. of Receipt. No. Receipt. Dt. Amount of
Institute Tuition Fees

Total

VERIFIED TODAY, THE _______________ DAY OF _________________, _______.

PLACE : ________________

_______________________
( Signature of the employee )
Encl. : Original Tuition Fee receipt

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